What is Bubble CPAP

Bubble Continuous Positive Airway Pressure (bCPAP) is a less invasive intervention compared to endotracheal intubation and mechanical ventilation. Health care providers may use bCPAP to help neonates and young infants with respiratory compromise associated with conditions such as respiratory distress syndrome of prematurity, neonatal sepsis, pneumonia, or difficult transitioning after birth (AKA transient tachypnea of the newborn).

Bubble CPAP intervention is best used for preterm and young infants who have mild to moderate respiratory disease. Therefore, bCPAP is not the right intervention for infants under heavy sedation or those who have severe lung disease. It is known to be the gentlest respiratory support as it applies the lowest pressure to the delicate neonatal lungs providing low to no oxygen. Bubble CPAP provides respiratory support to infants who can breathe on their own but cannot generate enough pressure to continue breathing for a long time. These infants are only placed on bCPAP until they can generate enough pressure indefinitely and don’t need the bcpap anymore. The use of bubble CPAP is shown to be associated with less chronic lung disease, a common condition seen in preterm infants.

Although bCPAP is a simple bedside intervention, it requires a specialized team to apply and monitor its implementation. Neonatal units familiar with bCPAP are known for having a lower incidence of chronic lung disease and better outcomes compared to national averages. A special culture of enhanced bedside management has to be established in these units and it requires family cooperation for its success. Infants managed with bCPAP are generally stable and, therefore, may be able to benefit from Kangaroo care while they are on bCPAP during earlier phases of their development compared to infants intubated and mechanically ventilated. Feeding by mouth is encouraged for infants on bCPAP once they reach the proper maturity (usually around 34 weeks corrected gestational age or post conceptual age).

Kangaroo care with bubble CPAP

Kangaroo care is skin-to-skin placement of a newborn against a human chest. Both the mother and the father can hold their infants in Kangaroo position while the newborn is on bCPAP.

Kangaroo care is almost a 50-year-old practice. It was initially intended for full term infants in the first few of hours of life to promote bonding of delivering mothers with their newly born infant(s) and to facilitate initiation of breast feeding. Later, it was introduced in the care of stable preterm infants who are admitted to the Neonatal ICU for several weeks or months. Many studies have shown that Kangaroo care has many benefits to preterm and full-term infants. Kangaroo care is associated with reduced mortality, infection and length of hospital stay. It has been shown to correlate with cardiorespiratory and temperature stability, improvement in neuro-developmental outcomes and breastfeeding.

We recommend Kangaroo care to infants who are clinically stable and who are at least 750g. Infants on bCPAP can be cared for in kangaroo position. These infants can stay in Kangaroo care as long as they are stable (no desaturations or bradycardia). Although, at such a young age they may not be ready for feeding by mouth. The bedside nurse will help you position your infant on your chest and will monitor the infant during kangaroo care.

In general, if the preterm infant require bubble CPAP with supplemental oxygen, they have to remain on bCPAP when having Kangaroo care. If no supplemental oxygen required and their weight is at least 1200g, they may be trialed off CPAP while kangarooing. Cardiorespiratory monitoring should continue during kangaroo Care

Mouth and breastfeeding with Bubble CPAP

Preterm infants are prepared for mouth feeding as early as 32 weeks corrected age. Infants on bCPAP may be considered for mouth feeding as early as 34 weeks if they are physiologically stable and showing cues of readiness for mouth feeding.

There were reports that associated mouth feeding with aspiration in infants on CPAP. These reports described continuous flow nasal cannula being used to deliver CPAP. In such conditions, airflow into the trachea (the lung pipe) is continuous during both inspiration and expiration. In bCPAP using nasal prongs as the nasal interface, although flow is continuous, air gets into the trachea during inspiration, but it rather passes through the transverse arm of the nasal interface then to the expiratory end during expiration. Therefore it may not be associated with pulmonary aspiration. Anecdotal observation from neonatal units which run successful bCPAP program, have been practicing feeding while on bCPAP. These units frequently use transverse nasal prongs. However, there is no enough evidence through scientific research to support such practice.
Preterm infants on bCPAP who reached functional maturity to feed by mouth, may be prepared to start mouth feeding while continuing on bCPAP. Breast feeding should be given priority over bottle feeding (if there are no contraindications). Preparation for mouth feeding may start earlier than 34 weeks by setting the infant in feeding position and try practicing non-nutritive sucking as long as the infant is physiologically stable. Mouth feeding may advance gradually. Breast feeding is the preferred method. Otherwise, different nipples may be tried until the best fit is identified.
Complication of BCPAP

Bubble CPAP is the mildest form of pressure support to the growing lung. It was shown to be associated with better outcomes and less chronic lung disease. In addition, Neonatal units who primarily use bCPAP are frequently experiencing less retinopathy of prematurity (a disease peculiar to preterm infants associated with exposure to high concentration of oxygen and may lead to loss of vision later in life).

Complications of prematurity such as infection or necrotizing enterocolitis can happen in preterm infant and bubble CPAP did not increase or decrease such condition. However, bCPAP may be associated with nasal septum thinning or erosion. These should be treated promptly and bCPAP need not to be stopped if the septum is intact. The bedside nurse should keep part of the nasal prongs outside the nose (1-2 mm) to avoid pressure on the nasal bridge.

Discharge planning

The use of bCPAP is associated with less chronic lung disease and therefore may be associated with less hospital stay and early discharge. However, it is not uncommon among infants <750g or <26 weeks at birth to encounter a long hospital course due to other complications or extreme lung immaturity.

The healthcare provider may opt to keep preterm infants on bubble CPAP even if they do not need supplemental oxygen anymore. This is because using bCPAP with 21% oxygen (room air) is better than using supplemental oxygen with devices such as nasal cannula. Supplemental oxygen is shown in many instances to be associated with increased lung inflammation, depressed immunity and therefore increased lung damage. On the contrary, bubble CPAP (21% oxygen) is shown to enhance lung growth in animal models. Infants who remain on bCPAP for longer and then wean successfully, likely, will not be discharged on supplemental oxygen at home. While infants weaned prematurely from CPAP to oxygen supplement via nasal cannula may be discharged on supplemental oxygen and remain on oxygen for several weeks after discharge.

For extremely premature infants to get discharged they need to fulfil certain criteria such as to be able to breathe on their own, feed in full on their own, and control their temperature outside an isolette (incubator). In addition, they need to meet a minimum weight at time of discharge (usually 4 pounds but this may vary from institution to another) and be free of significant events such as apnea, bradycardia or desaturations. There are many other steps that are considered before discharge and these vary by institution. Preterm infants may need to be discharged on some medications, such as diuretics, vitamins, etc. Parents need to familiarize themselves with these measures to better prepare for their infant’s discharge.